Michael Campbell

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation
into the death of
Mr Michael Campbell
on 22 February 2025, following
his release from HMP Lewes
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2026
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
1. The Prisons and Probation Ombudsman aims to make a significant contribution to
safer, fairer custody and community supervision. One of the most important ways in
which we work towards that aim is by carrying out independent investigations into
deaths, due to any cause, of prisoners, young people in detention, residents of
approved premises and detainees in immigration centres.
2. If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate,
our recommendations should be focused, evidenced and viable. This is especially
the case if there is evidence of systemic failure.
3. Since 6 September 2021, the PPO has investigated post-release deaths that occur
within 14 days of the person’s release from prison.
4. Mr Michael Campbell died from mixed drug intoxication and bronchopneumonia on
22 February 2025, following his release from HMP Lewes on 19 February 2025. He
was 42 years old. We offer our condolences to those who knew him.
5. We did not identify any significant learning relating to the pre-release planning or
post-release supervision of Mr Campbell.
6. We make no recommendations.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
7. HMPPS notified us of Mr Campbell’s death on 27 February 2025.
8. The PPO investigator obtained copies of relevant extracts from Mr Campbell’s
prison and probation records.
9. The investigator interviewed Mr Campbell’s Community Offender Manager on 8
May 2025.
10. We informed HM Coroner for Portsmouth and Southeast Hampshire of the
investigation. He gave us the results of the post-mortem examination. We have sent
the Coroner a copy of this report.
11. The Ombudsman’s office contacted Mr Campbell’s family to explain the
investigation and to ask if they had any matters they wanted us to consider. They
asked what mental health support was in place for Mr Campbell and asked for a
copy of our report.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
13. Mr Campbell’s family received a copy of the draft report. They did not make any
comments.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Lewes
14. HMP Lewes is a category B prison which holds convicted male prisoners. It is
managed by HMPPS.
Probation Service
15. The Probation Service works with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, prepare reports to advise the Parole Board and have links
with local partnerships to which they refer people for resettlement services, where
appropriates. Post-release, the Probation Service supervises people throughout
their licence period and post-sentence supervision.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
Background
16. On 7 August 2023, Mr Michael Campbell was remanded to HMP Winchester. On 15
March 2024, Mr Campbell was sentenced to 27 months in prison for stalking.
17. On 2 April, Mr Campbell was sent to HMP Guys Marsh.
18. While at Guys Marsh, Mr Campbell engaged with the substance misuse team. He
said he had a history of substance use but wanted to reduce this and make positive
changes in his life.
19. In the following months, prison staff found Mr Campbell under the influence of drugs
several times. On each occasion, staff opened welfare logs to monitor him and
sought medical attention from healthcare staff. Following these incidents, Mr
Campbell’s substance misuse recovery worker also conducted welfare checks and
gave him harm minimisation and safer use advice.
20. On 29 July, Mr Campbell was released from Guys Marsh on an End of Custody
Supervised Licence (ECSL which ran from May to September 2024 and allowed
prisoners to be released up to 70 days early). Mr Campbell was released to an
Approved Premises. Once his placement came to an end, he was housed by the
council in Portsmouth.
21. While on licence, Mr Campbell engaged well with the Probation Service. At
interview, Ms A, a Community Offender Manager (COM), told us that Mr Campbell
attended his appointments as instructed, however he did not engage with any
interventions, including for his mental health issues. Ms A told us that she referred
Mr Campbell to Catch-22 (the local wellbeing support service), but he did not
engage. She also referred him to Reconnect (a care after custody service that
seeks to improve the continuity of health care of people leaving prison), who he had
some contact with.
22. Ms A told us that during Mr Campbell’s time in the community, she regularly drug
tested him, and his results were consistently positive. She referred him to the
Recovery Hub (the local substance misuse service) to address his substance use,
and Mr Campbell engaged with the service initially.
23. On 23 January 2025, Mr Campbell breached his licence and was recalled to prison
on a 28-day fixed-term recall. He was sent to HMP Lewes.
24. During the reception health screen, a nurse noted that Mr Campbell had a history of
substance use. He said he had been diagnosed with bi-polar disorder, post-
traumatic stress disorder (PTSD) and spina bifida. She referred him to the
substance misuse team and the mental health team.
25. On 24 January, the mental health team booked a triage appointment after receiving
the referral. They noted that Mr Campbell had a diagnosis of bi-polar disorder and
had not taken any medication for several days. They conducted a medication
reconciliation, and prescribed Mr Campbell with naproxone for his spina bifida and
quetiapine for bi-polar disorder.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
26. Later that day, a recovery worker from the substance misuse team met with Mr
Campbell. They discussed poly-drug use, low tolerance after a period of
abstinence, signs and symptoms of overdose and mixing medication with alcohol.
The recovery worker did not refer Mr Campbell to the community substance misuse
service as Mr Campbell said he did not want to engage with them once released.
The recovery worker offered Mr Campbell naloxone (which can reverse the effects
of an opioid overdose) training, but he declined.
27. On 26 January, a mental health nurse met with Mr Campbell to conduct a mental
health assessment. She agreed to discuss Mr Campbell’s case at the next multi-
disciplinary team meeting and to consider one-to-one trauma support. She noted
that Mr Campbell was engaging with the substance misuse team and said he would
also be managed by the mental health team.
28. On 30 January, Mr Campbell was discharged from the substance misuse team after
they assessed that clinical monitoring was no longer necessary because Mr
Campbell was not presenting with any signs of withdrawal.
Pre-release planning
29. On 28 January, Ms B, a Prison Offender Manager (POM), met with Mr Campbell to
introduce herself and explain her role. They spoke about Mr Campbell’s recall to
prison, his accommodation as he was unsure if he could return to his property upon
release and his substance use. Following the meeting, Ms B emailed Ms A to share
what had been discussed. Ms A emailed the local council to check if Mr Campbell’s
property would still be available to him upon release and copied Ms B into the
email.
30. Ms A told us during interview, that she did not meet with Mr Campbell following his
recall as it was a 28-day fixed term recall and she did not have sufficient time. She
told us that she liaised with the local council to ensure Mr Campbell would have
accommodation upon release and liaised with the community substance misuse
service and the wellbeing service to notify them that Mr Campbell had been
recalled, but would still require their support once released, to ensure the referrals
stayed open.
31. On 10 February, Ms A emailed the prison with details of Mr Campbell’s licence
conditions and reporting instructions. She added several additional conditions
including non-contact with the victim of his offence, exclusion zones, GPS
monitoring, drug testing and alcohol monitoring. The licence conditions were the
same as those on Mr Campbell’s previous licence.
Post-release management
32. On 19 February, Mr Campbell was released from Lewes. He was released with his
medication, but not naloxone.
33. At 2.30pm, Mr Campbell attended his induction appointment at Portsmouth
probation office with Ms A and Ms C (another COM who was due to take over Mr
Campbell’s case). Ms A spoke to Mr Campbell about his recall, his additional
licence conditions, and his substance use. She said he should go straight to his
property to ensure it was still available to him and directed him to attend the
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
substance misuse service. Ms C gave Mr Campbell his next appointment for 24
February.
34. During interview, Ms A told the investigator that she did not hear from Mr Campbell
after the appointment so assumed there were no issues with his accommodation.
Circumstances of Mr Campbell’s death
35. On 22 February, a resident at Mr Campbell’s property called the police to notify
them that he had found Mr Campbell dead in his bedroom. Police attended at
8.05pm and found Mr Campbell, with rigor mortis present. They confirmed his death
at 8.11pm. The police found drug paraphernalia and a half empty bottle of cider in
Mr Campbell’s bedroom. An ambulance did not attend as there were no life-saving
opportunities.
Post-mortem report
36. The post-mortem report concluded that Mr Campbell died from mixed drug
intoxication (methylenedioxymethamphetamine (MDMA), diacetylmorphine (heroin),
pregabalin, cocaine) and bronchopneumonia.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
37. Our investigation found that staff completed appropriate pre-release planning,
including referrals to the community substance misuse service for Mr Campbell, but
he had indicated that he did not wish to engage. We did not identify any significant
learning relating to the pre-release planning or post-release supervision of Mr
Campbell.
38. We are satisfied that Mr Campbell was offered appropriate support to manage the
risks associated with his substance use.
Adrian Usher
Prisons and Probation Ombudsman November 2025
Inquest
At the inquest held on 27 January 2026, the Coroner concluded that Mr Campbell’s
intention at the time of ingesting the drugs could not be ascertained.
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE